Intraoperative Splenic Injuries

Abstract

Intraoperative splenic injuries can occur in any abdominal surgical procedure. Reports range from vascular surgeons performing abdominal aortic aneurysm repairs to thoracic surgeons performing Nissen fundoplication to urologists performing radical nephrectomies [1]. Injury to the spleen during laparoscopic urological surgery has a reported incidence of 0.25% [2]. The reported incidence of splenic injury resulting in splenectomy during colonic surgery is 1.2–8%. The highest percentage of all incidental splenectomies are due to colonic surgeries, primarily to a large number of these operations and the close proximity between the colonic splenic flexure and the spleen [3]. Injuries to the spleen during laparoscopic adrenalectomy may be either access-related or caused by powerful retraction and handling of the organ [4].

Introduction

Intraoperative splenic injuries can occur in any abdominal surgical procedure. Reports range from vascular surgeons performing abdominal aortic aneurysm repairs to thoracic surgeons performing Nissen fundoplication to urologists performing radical nephrectomies [1]. Injury to the spleen during laparoscopic urological surgery has a reported incidence of 0.25% [2]. The reported incidence of splenic injury resulting in splenectomy during colonic surgery is 1.2–8%. The highest percentage of all incidental splenectomies are due to colonic surgeries, primarily to a large number of these operations and the close proximity between the colonic splenic flexure and the spleen [3]. Injuries to the spleen during laparoscopic adrenalectomy may be either access-related or caused by powerful retraction and handling of the organ [4].

Splenic injury may occur as a result of two etiologies. The first is due to traction injuries from excessive retraction of the spleen, resulting in a capsular tear or laceration. This is attributable to inadequate release of the ligamentous attachment of the spleen to surrounding structures. The second etiology is due to trauma from the instruments used during surgery.

Up to 40% of all splenectomies are performed for iatrogenic injury. The risk of splenic injury is highest during left hemicolectomy (1–8%), open antireflux procedures (3–20%), left nephrectomy (4–13%), and during exposure and reconstruction of the proximal abdominal aorta and its branches (21–60%). Splenic injury results in prolonged operating time, increased blood loss, and longer hospital stay. It is also associated with a two to tenfold increase in infection rate and up to a doubling of morbidity rates. Mortality rates are also reported to be higher in patients undergoing splenectomy for iatrogenic injury [5].

When splenic injury occurs intraoperatively, the surgeon is faced with the dilemma of whether to perform immediate splenectomy or treat the injury conservatively. The spleen is instrumental in immunity, especially with regards to encapsulated organisms. Splenectomy decreases resistance to certain infectious etiologies, necessitating prophylactic immunization. However, conservative treatment of a splenic laceration can be quite problematic owing to the friable and unforgiving nature of the splenic parenchyma, which may result in delayed hemorrhage and eventual splenectomy [2].

Management

The majority of splenic and liver injuries during laparoscopic surgery are minor capsular lesions which usually can be managed laparoscopically [6]. Splenic injuries that are dealt with conservatively will require multiple definitive hemostatic measures, and direct pressure alone is unlikely to provide durable success [2]. These injuries are typically sufficiently controlled with the combination of pressure and application of oxidized regenerated cellulose (Surgicel), absorbable gelatin sponges (Gelfoam), and fibrin glue (Tissucol) [4].

In a study by Coln et al., Gelfoam was the least effective in achieving hemostasis. It was also the least satisfactory agent studied from a convenience standpoint. Surgicel was much easier to use than Gelfoam and appeared to achieve faster hemostasis. Surgicel adhered well when applied to the lacerated surface and occasionally needed a second layer before hemostasis was achieved [7].

The use of fibrin sealants for rapid and definitive hemostasis for splenic injuries was described by Canby-Hagino et al. Fibrin sealant achieved adequate immediate hemostasis and each patient recovered without further splenic bleeding. It is simple to use in the open and laparoscopic approaches [8].

The use of gelatin thrombin granules (FloSeal), argon beam coagulator, and Surgicel was described by Chung et al. FloSeal consists of a gelatin matrix and a Thrombin component, which are mixed together before use. Cross-linked gelatin granules in the matrix swell approximately 20% on contact with blood or bodily fluids, slowing blood flow. The coagulation cascade is activated by the thrombin component to form a firm hemostatic plug. These two processes combine to effect hemostasis by tamponade [9]. Argon beam coagulator delivers radiofrequency electrical energy to tissue across a jet of argon gas, providing noncontact, monopolar, electrothermal hemostasis [10]. After evaluation of the extent of injury, Surgicel is initially placed on the injured area to provide hemostasis. If bleeding does not stop with the first application of Surgicel. Immediate coagulation of the area with the argon beam coagulator with application of FloSeal and additional Surgicel is done at the completion of every case, pneumoperitoneum is evacuated for 5 min and the site is reinspected to ensure perfect hemostasis. General surgery consultation is obtained if the bleeding does not stop with the application of argon beam, FloSeal, and Surgicel, or if the bleeding recurs after the 5 min pneumoperitoneum evacuation trial period. Laparoscopic splenectomy may be required in difficult situations (Fig. 1) [2]. More extensive lacerations to the spleen may warrant open conversion.

Fig. 1

Algorithm for optimal treatment of intraoperative splenic injury [2]